Treating UTI in the Outpatient Setting
the MPR take:
What is the best approach to diagnosing and managing acute cystitis in the outpatient setting? Given the prevalence of antibacterial resistance, which further complicates treatment, a new article in The Journal of the American Medical Association (JAMA) reviews optimal approaches to treating urinary tract infections (UTI) in adult patients. Based on this large review (27 randomized clinical trials, 6 systematic reviews, and 11 observational reviews), which included healthy women, women with diabetes, and men, researchers concluded that for uncomplicated cystitis, first-line therapy can be one of the following three regimens: trimethoprim-sulfamethoxazole 160/800mg twice daily for 3 days; fosfomycin trometamol 3g in a single dose; or nitrofurantoin monohydrate/ macrocrystals 100mg twice daily for 5–7 days. Beta-lactam antibiotics such as amoxicillin-clavulanate and cefpodoxime-proxetil do not appear to be as effective as these first-line therapies. While fluoroquinolone antibiotics are effective for treating UTI, they should be reserved for more complicated infections. The researchers also point out that rather than managing the symptoms of UTI with ibuprofen alone and delaying antimicrobial treatment, immediate antibiotic therapy should be initiated. Women with diabetes should be treated similarly to women without diabetes as long as there are no voiding abnormalities; this recommendation, however, was based on expert opinion and one observational study. For men, there is limited evidence to support treating acute UTI for 7–14 days. The researchers conclude that therapy should be individualized to the patient based on regimen tolerability and risk factors for resistance.
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